Each year, antimicrobial resistant infections cause more than 2 million illnesses and 23,000 deaths in the U.S., according to the Centers for Disease Control and Prevention (CDC). Most deaths related to antibiotic resistance occur in healthcare settings, leaving hospitals susceptible to the costs, readmissions and potential legal liability.
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To optimize treatment of infections and reduce adverse events associated with antimicrobial resistance, many hospitals have established in-house antimicrobial stewardship programs dedicated to improving antibiotic use.
However, most antibiotic stewardship programs are not as robust as they could be, according to Michael Osterholm, PhD, professor of public health at the University of Minnesota and founding director at the Center for Infectious Disease Research and Policy, known as CIDRAP. At a Nov. 13 workshop at the Becker's Hospital Review 6th Annual CEO + CFO Roundtable in Chicago, Dr. Osterholm pointed out that many antibiotic stewardship programs are just getting started. While the CDC and The Joint Commission require hospitals to implement these programs in order to optimize the treatment of infections and reduce adverse events associated with antibiotic use, less than half are evidence-based, he explained.
"I must admit on a whole, we have not taken these areas as seriously as we can and should. I'm embarrassed to say in my own home state of Minnesota, only 24 percent of hospitals had a recognized antibiotic stewardship program in place [in 2015]," he said.
Russ Nassof, executive vice president of consulting firm RiskNomics, added that hospitals lacking evidence-based antimicrobial stewardship programs carry the most legal risk.
"The problem is, if you have an antibiotic stewardship program that isn't evidence-based, it encourages antimicrobial resistance, which proliferates cases of sepsis and instances of hospital-acquired infections like C. diff. That's when questions of responsibility arise," he told attendees.
Mr. Nassof urged hospitals to follow four steps to establish an evidence-based antimicrobial stewardship program.
1. Define the standard of care
From a legal perspective, the "standard of care" refers to how a similarly qualified physician would have cared for a patient under normal circumstances, according to Mr. Nassof.
"The burden of proof is on you to show that you have protected that patient/invitee from harm. If a patient develops sepsis or C. diff, there may be inferences of potential negligence, such as failing to meet the standard of care," Mr. Nassof said. It is important to note physicians can make mistakes while following the standard of care, which is different than negligence.
2. Avoid negligence
Medical professionals expose themselves to greater legal risk when they do not adhere to the standard of care and potential negligence results in harm to the patient.
"The failure to have an effective antimicrobial stewardship program, which results in HAIs such as sepsis and C. diff, can be negligent and result in liability and cost," Mr. Nassof said. Hospitals must ensure they meet evidence-based criteria when establishing an antimicrobial stewardship program to avoid negligence, Mr. Nassof noted.
3. Strive for evidence-based antimicrobial protocols
Evidence-based medicine is a problem-solving approach integrating the best scientific experiments coupled with patient satisfaction. Mr. Nassof stressed using evidence-based medicine often means performing beyond customary medical protocols.
"All too often, we want to hide behind the guidelines. But unfortunately, the courts are not looking at what is customary. The courts are looking at what is reasonable," he explained. "In order to meet the reasonable standard you need to comply with current best evidence, even if that means that a small reputable subset of professionals are following that or adhering to that technology."
4. Execute an evidence-based antimicrobial stewardship program
To implement an evidence-based antimicrobial stewardship program, Dr. Osterholm urged hospitals to avoid complexity by advocating for practical changes.
"Clinicians love to be independent operators, they are trained their whole career to interface with their patients in such a manner and the last thing they want is someone telling them what to do. What we have to do is basically share with them how they can improve their clinical care, when they are in control and have at their fingertips the best possible information in the quickest possible time," Dr. Osterholm added.
Practical evidence-based antimicrobial programs comprise five characteristics, according to Mr. Nassof:
- Good leadership
- Accountability
- Multidisciplinary involvement
- Drug expertise
- Action
Mr. Nassof added once executed, evidence-based antimicrobial programs require continual reassessment of patient needs, emerging treatments, drug doses and duration, and identifying potential legal risk.
This is because antimicrobial stewardship programs aren't a one-time meeting between a physician and a patient. Rather, these programs are active, ongoing oversight to ensure the right drugs are being administered to patients, Dr. Osterholm explained.
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